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Transparency in Coverage Model Notice
FCA US LLC Health Care Benefits Plan
01-01-2023
You are receiving this notice because you requested a cost estimate for an item or service. This notice contains important information about the cost estimate and information on the amount you may ultimately be required to pay for this item or service.
I. The Basics
What should I do with this notice?
Read this notice carefully along with the cost estimate. You may need to request a new cost estimate as you obtain new information, such as information on additional items or services you will receive as part of your treatment.
What are the key terms?
- An Allowed Amount is the maximum amount your health plan will pay for a covered item or service furnished by an out-of-network provider. There is no allowed amount for service furnished by an out-of-network provider by your health plan.
- Cost-Sharing is your share of costs for a covered item or service that you must pay (sometimes called “out-of-pocket costs”). Some examples of cost-sharing are deductibles, coinsurance, and copayments. This term does not include other costs you may receive a bill and will be responsible billed for billed amounts for out-of-network providers, or the cost of services not covered by your health plan.
- A Covered Item or Service is an item or service that your health plan will pay, either in whole or in part, under the terms of your health plan.
- An Out-of-Network Provider is a provider that does not have a contract with your plan to provide services at pre-negotiated rates.
- Prerequisites are certain requirements your health plan may impose on you or your provider so that it can determine whether a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary before it will provide benefits for related items and services. Prerequisites include prior authorization, concurrent review, and step-therapy or fail-first requirements.
Other common medical and insurance terms, including definitions of deductibles, coinsurance, and copayments, can be found in the Uniform Glossary of Coverage and Medical Terms.
II. Important information about your cost estimate
This estimate is designed to provide you with information about the cost of an item or service before you receive care. However, this estimate has certain limitations that you should consider before making any decision to obtain the item or service.
- If you are treated by an out-of-network provider, it is not a covered benefit. You may receive a bill from the out-of-network provider. This amount is not included in your cost estimate.
- The actual charge for the item or service may be different than the cost estimate, depending on the actual care you receive. For example, if your physician provides additional services during your visit, your charges could be more than the cost estimate. This is one reason why it is important to discuss with your provider both before and during your visit which items and services you will receive and to request a new cost estimate if new information becomes available.
- This cost estimate is not a benefit determination or guarantee of coverage for the item or service for which you requested information. For example, your plan may need to determine whether the item or service is medically necessary in your case before making a payment. You should follow your health plan’s process for filing a claim for benefits and contact your health plan to help determine if there are any additional requirements that apply to you as part of that process.
III. Prerequisites
Prior Authorization
Your health plan must decide whether this item or service is medically necessary before it will cover this item or service. This is called prior authorization. Your health plan may impose additional costs if you or your provider do not submit this item or service for prior authorization before the item or service is provided.
Concurrent Review
Your health plan may require a review during an ongoing course of treatment to determine whether the plan will continue to cover the item or service. This is called concurrent review. Your health plan may cease covering treatment if you or your provider do not submit this item or service for concurrent review within a specified time period after beginning treatment.
IV. What if I need more information?
Contact: TheraMatrix Physical Therapy Network at (888) NET-TPTN or (888)638-8786.Transparency in Coverage Model Notice
Ford Health Plan
01-01-2023
You are receiving this notice because you requested a cost estimate for an item or service. This notice contains important information about the cost estimate and information on the amount you may ultimately be required to pay for this item or service.
I. The Basics
What should I do with this notice?
Read this notice carefully along with the cost estimate. You may need to request a new cost estimate as you obtain new information, such as information on additional items or services you will receive as part of your treatment.
What are the key terms?
- An Allowed Amount is the maximum amount your health plan will pay for a covered item or service furnished by an out-of-network provider. There is no allowed amount for service furnished by an out-of-network provider by your health plan.
- Cost-Sharing is your share of costs for a covered item or service that you must pay (sometimes called “out-of-pocket costs”). Some examples of cost-sharing are deductibles, coinsurance, and copayments. This term does not include other costs you may receive a bill and will be responsible billed for billed amounts for out-of-network providers, or the cost of services not covered by your health plan.
- A Covered Item or Service is an item or service that your health plan will pay, either in whole or in part, under the terms of your health plan.
- An Out-of-Network Provider is a provider that does not have a contract with your plan to provide services at pre-negotiated rates.
- Prerequisites are certain requirements your health plan may impose on you or your provider so that it can determine whether a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary before it will provide benefits for related items and services. Prerequisites include prior authorization, concurrent review, and step-therapy or fail-first requirements.
Other common medical and insurance terms, including definitions of deductibles, coinsurance, and copayments, can be found in the Uniform Glossary of Coverage and Medical Terms.
II. Important information about your cost estimate
This estimate is designed to provide you with information about the cost of an item or service before you receive care. However, this estimate has certain limitations that you should consider before making any decision to obtain the item or service.
- If you are treated by an out-of-network provider, it is not a covered benefit. You may receive a bill from the out-of-network provider. This amount is not included in your cost estimate.
- The actual charge for the item or service may be different than the cost estimate, depending on the actual care you receive. For example, if your physician provides additional services during your visit, your charges could be more than the cost estimate. This is one reason why it is important to discuss with your provider both before and during your visit which items and services you will receive and to request a new cost estimate if new information becomes available.
- This cost estimate is not a benefit determination or guarantee of coverage for the item or service for which you requested information. For example, your plan may need to determine whether the item or service is medically necessary in your case before making a payment. You should follow your health plan’s process for filing a claim for benefits and contact your health plan to help determine if there are any additional requirements that apply to you as part of that process.
III. Prerequisites
Prior Authorization
Your health plan must decide whether this item or service is medically necessary before it will cover this item or service. This is called prior authorization. Your health plan may impose additional costs if you or your provider do not submit this item or service for prior authorization before the item or service is provided.
Concurrent Review
Your health plan may require a review during an ongoing course of treatment to determine whether the plan will continue to cover the item or service. This is called concurrent review. Your health plan may cease covering treatment if you or your provider do not submit this item or service for concurrent review within a specified time period after beginning treatment.
